Provider Demographics
NPI:1508937913
Name:KEELING, BONITA (MPT PCS)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:
Last Name:KEELING
Suffix:
Gender:F
Credentials:MPT PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19142 BIG TIMBER ROAD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703
Mailing Address - Country:US
Mailing Address - Phone:903-780-3505
Mailing Address - Fax:
Practice Address - Street 1:2808 S MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771
Practice Address - Country:US
Practice Address - Phone:903-780-3505
Practice Address - Fax:903-881-6010
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1122315225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84132T, 63657OtherBCBS PAR, BCBS BLUE LINK
TX36621603Medicaid
TX366216502Medicaid